Bedsores (pressure ulcers)

Overview

Bedsores are injuries to the skin and the tissue below the skin that are due to pressure on the skin for a long time. Bedsores most often arise on skin that covers bony areas of the body, such as the heels, ankles, hips and tailbone. Bedsores also are called pressure ulcers, pressure injuries and decubitus ulcers.

The people who are most at risk of bedsores have medical conditions that keep them from changing positions or moving. Or they spend most of their time in a bed or a chair.

Bedsores can arise over hours or days. Most sores heal with treatment, but some never heal completely. You can take steps to put a stop to bedsores and help them heal.

Symptoms

Symptoms of bedsores are:

• Changes in skin color or texture.
• Swelling.
• Pus-like draining.
• An area of skin that feels cooler or warmer to the touch than other areas.
• Sore areas.

Bedsores fall into one of several stages based on their depth, how serious they are and other features. The degree of skin and tissue damage ranges from inflamed, unbroken skin to a deep injury involving muscle and bone.

Common sites of pressure ulcers

For people who use wheelchairs, bedsores often occur on skin over these areas:

• Tailbone or buttocks.
• Shoulder blades and spine.
• Backs of arms and legs where they rest against a chair.

For people who need to stay in bed, bedsores may happen on the:

• Back or sides of the head.
• Shoulder blades.
• Hip, lower back or tailbone.
• Heels, ankles and skin behind the knees.

When to see a doctor

If you notice warning signs of a bedsore, change your position to ease pressure on the area. If the area doesn't improve in 24 to 48 hours, contact your healthcare professional.

Seek medical care right away if you notice signs of infection. These include fever, drainage from a sore or a sore that smells bad, as well as warmth or swelling around a sore.

Causes

Pressure against the skin that limits blood flow to the skin causes bedsores. Limited movement can make skin prone to damage and cause bedsores.

The three main things that lead to bedsores are:

• Pressure. Constant pressure on any part of the body can lessen the blood flow to tissues. Blood flow is essential to deliver oxygen and other nutrients to tissues. Without these key nutrients, skin and nearby tissues are damaged and might die over time. Limited movement can make skin prone to the damage that the pressure causes. For people with limited mobility, pressure tends to happen in areas that aren't well padded with muscle or fat and that lie over a bone. These areas include the spine, tailbone, shoulder blades, hips, heels and elbows.
• Friction. Friction occurs when the skin rubs against clothing or bedding. It can make fragile skin more vulnerable to injury, especially if the skin also is moist.
• Shear. Shear occurs when two surfaces move in the opposite direction. For example, when a bed is raised at the head, a person can slide down in bed. As the tailbone moves down, the skin over the bone might stay in place, pulling in the opposite direction.

Risk factors

Your risk of getting bedsores is higher if you have a hard time moving and can't change position easily while seated or in bed. Risk factors include:

• Immobility. This might be due to poor health, spinal cord injury or another cause.
• Incontinence. Skin becomes more vulnerable with extended exposure to urine and stool.
• Lack of sensory perception. Spinal cord injuries, neurological disorders and other conditions can make you lose sensation. If you can't feel pain or discomfort, you won't be aware of warning signs and the need to change position.
• Poor nutrition and hydration. People need enough fluids, calories, protein, vitamins and minerals every day to maintain healthy skin and stop the breakdown of tissues.
• Medical conditions affecting blood flow. Health problems that can affect blood flow can raise the risk of tissue damage such as bedsores. Examples of these types of medical conditions are diabetes and vascular disease.
• Age. If you're over 70, you're more likely to be affected by bedsores.

Complications

Complications of pressure ulcers include:

• Cellulitis. Cellulitis is an infection of the skin and connected soft tissues. It can cause warmth and swelling of the affected area. The skin may change color or look inflamed. People with nerve damage often don't feel pain in the area cellulitis affects.
• Bone and joint infections. An infection from a bedsore can burrow into joints and bones. Joint infections, such as septic arthritis, can damage cartilage and tissue. Bone infections, also known as osteomyelitis, can reduce the function of joints and limbs.
• Cancer. A Marjolin ulcer is a long-term, nonhealing wound that can become a type of squamous cell carcinoma.
• Sepsis. Rarely, a skin ulcer leads to sepsis, which is a life-threatening complication of an infection.

Some complications can be life-threatening.

Prevention

You can help stop bedsores with these steps:

• Frequently change your position to avoid stress on the skin.
• Take good care of your skin.
• Eat and drink regularly.
• Quit smoking.
• Manage stress.
• Exercise daily.

Tips for repositioning

Consider these recommendations related to changing position in a bed or chair:

• Shift your weight frequently. Ask for help with changing your position every two hours.
• Lift yourself, if possible. If you have enough upper body strength, do wheelchair pushups. Raise your body off the seat by pushing on the arms of the chair.
• Look into a specialty wheelchair. Some wheelchairs allow you to tilt them, which can relieve pressure.
• Select cushions or a mattress that relieves pressure. Use cushions or a special mattress to relieve pressure and help make sure that your body is well positioned. Do not use doughnut cushions. They can focus pressure on surrounding tissue.
• Adjust the height of your bed. If possible, do not raise the head of the bed above 30 degrees. This helps prevent shearing.

Tips for skin care

Consider these suggestions for skin care:

• Keep skin clean and dry. Wash the skin with a gentle cleanser and pat dry. Do this cleansing routine regularly to limit the skin's exposure to moisture, urine and stool.
• Protect the skin. Use moisture barrier creams to protect the skin from urine and stool. Change bedding and clothing frequently if needed. Watch for buttons on the clothing and wrinkles in the bedding that can irritate your skin.
• Inspect the skin daily. Look closely at your skin daily for warning signs of a bedsore.

Diagnosis

Your healthcare professional likely will look closely at your skin to decide if you have a pressure ulcer. If a pressure ulcer is found, your healthcare professional will assign a stage to the wound. Staging helps determine what treatment is best for you. You might need blood tests to learn about your general health.

Questions from the doctor

Your healthcare professional might ask questions such as:

• When did the bedsores first appear?
• How painful are the bedsores?
• Have you had bedsores before?
• How were they treated, and what was the outcome of treatment?
• What kind of care assistance is available to you?
• What is your routine for changing positions?
• What medical conditions have you been diagnosed with, and what is your current treatment?
• What do you usually eat and drink?

Treatment

Treating pressure ulcers involves lowering pressure on the affected skin, caring for wounds, controlling pain, preventing infection and eating well.

Treatment team

Members of your care team might include:

• A primary care professional who oversees the treatment plan.
• A healthcare professional specializing in wound care.
• Nurses or medical assistants who provide care and education to manage wounds.
• A social worker who helps you or your family access resources and focus on emotional concerns related to long-term recovery.
• A physical therapist who helps you move better.
• An occupational therapist who helps make sure seating surfaces are right.
• A dietitian who tracks what you need to eat and recommends a good diet.
• A healthcare professional who specializes in skin conditions, also known as a dermatologist.
• A neurosurgeon, vascular surgeon, orthopedic surgeon or plastic surgeon.

Reducing pressure

The first step in treating a bedsore is to lower the pressure and friction that caused it. Try to:

• Change position. If you have a bedsore, turn and change your position often. How often you change your position depends on your condition and the quality of the surface you are on.
• Use support surfaces. Use a mattress, bed and special cushions that help you sit or lie in a way that protects vulnerable skin.

Cleaning and dressing wounds

Care for pressure ulcers depends on how deep the wound is. Generally, tending to a wound includes these steps:

• Clean. If the affected skin isn't broken, wash it with a gentle cleanser and pat dry. Clean open sores with water or saline each time a dressing is changed. Saline is a saltwater solution.
• Put on a bandage. A bandage speeds healing by keeping the wound moist. It also creates a barrier against infection and keeps the skin around it dry. Bandage choices include films, gauzes, gels, foams and treated coverings. You might need a combination of bandages.

Removing damaged tissue

To heal properly, wounds need to be free of damaged, dead or infected tissue. The healthcare professional may remove damaged tissue, also known as debriding, by gently flushing the wound with water or cutting out damaged tissue.

Other interventions

Other interventions include:

• Medicines to control pain. Nonsteroidal anti-inflammatory drugs, also known as NSAIDs, such as ibuprofen (Advil, Motrin IB, others) and naproxen sodium (Aleve, others), might reduce pain. These can be very helpful before or after changing position and with wound care. Pain medicines applied to the skin also can help during wound care.
• A healthy diet. Good nutrition promotes wound healing.

Surgery

A large bedsore that fails to heal might require surgery. One method of surgical repair is to use padding from your muscle, skin or other tissue to cover the wound and cushion the affected bone. This is called flap surgery.

Coping and support

People with bedsores may have discomfort. They also can be socially isolated or depressed. Talk with your healthcare team about your needs for support and comfort. A social worker can help find community groups that provide services, education and support for people dealing with long-term caregiving or terminal illness.

Parents or caregivers of children with bedsores can talk with a child life specialist for help in coping with stressful health situations. Family and friends of people living in assisted living facilities can support residents and work with nursing staff to make sure they receive the proper preventive care.